Complete Care at Southpointe
Greenfield, Wisconsin · CCN 525604
44 surveys since 2011, 32 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 242
- Surveys
- 44
- Harm or worse
- 32
- Immediate jeopardy
- 14
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 174
- Ownership
- For profit - Limited Liability company
- Chain
- COMPLETE CARE
- County
- Milwaukee
- Medicare-certified since
- 1996
CMS ratings
- Overall
- 4
- Health inspection
- 3
- Staffing
- 3
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 15 for-profit facilities with 128 or more beds in Wisconsin.
Last survey on record
Mar 12, 2026
242 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.70 | 3.71 |
| Registered-nurse hours per resident day | 0.71 | — |
| Annual nurse turnover | 47.4% | 58.8% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J211.8% | K— | L— |
| Actual harm | G211.8% | H— | I— |
| No harm, potential for more than minimal | D635.3% | E317.6% | F211.8% |
| No harm, potential for minimal | A— | B— | C211.8% |
Most frequently cited here
In CMS’s current monthly file.
- F6862×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F6021×
Protect each resident from the wrongful use of the resident's belongings or money.
- F6071×
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- F6231×
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
In the surveyor’s words
From the most serious findings on record at Complete Care at Southpointe, in the surveyor’s own words.
- Immediate jeopardy, patternF678Apr 7, 2022
Based on interview and record review, the facility did not have a system to ensure that there was someone working each shift who was certified in CPR (cardiopulmonary resuscitation, which had the potential to affect 93 of 144 residents who are full code. The facility did not immediate basic life support, including Cardio Pulmonary Resuscitation (CPR) to 1(R188) of 2 residents who was unresponsive. On [DATE] during the night shift, R188 was found unresponsive by Certified Nursing Assistant (CNA) L. CNA L told Registered Nurse (RN) H about R188 being unresponsive and RN H did not immediately perform life saving measures. RN H did not assess R188's breathing or pulse. […]
- Immediate jeopardy, isolatedF686Aug 17, 2023
Based on observation, interview and record review, the Facility did not ensure that Residents with pressure injuries or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R15, R406, R19, R24, and R83) of 6 sampled residents reviewed for pressure injuries. *When R15 was identified to have a new open area to the left buttock on 01/05/23, the facility failed to immediately assess R15's new open area and failed to adjust R15's plan of care to prevent the open are from declining to a stage 4 pressure injury on 03/02/23. *R406 returned to the facility on [DATE] after surgery with a new back brace. […]
- Immediate jeopardy, isolatedF689Aug 17, 2023
Based on observation, interview and record review the facility did not ensure 5 (R106, R24, R83, R206 & R103) of 11 residents reviewed were kept free from accidents and hazards. * On [DATE], R106 was provided incontinence care with improper technique by a Certified Nursing Assistant leading to a fall with cervical spine fracture, broken rib and scalp laceration. R106 returned to the facility on [DATE]. On [DATE], R106 expired at the facility. The medical examiner's office ruled R106's cause of death was due to injuries R106 sustained from their fall from bed on [DATE]. […]
- Immediate jeopardy, isolatedF684Apr 7, 2022
Based on interview and record review the facility did not ensure 1 (R188) of 1 resident experiencing a change in condition and eventually becoming unresponsive received the necessary RN assessment to prevent further decline. On [DATE] into [DATE] during the night shift, R188 experienced a change in condition. R188 was having vomiting episodes and Certified Nursing Assistant (CNA) L twice notified Registered Nurse (RN) H. RN H did not assess R188. Around 5:00 a.m. R188 was found unresponsive; an assessment still was not completed and R188 died at the facility. The facility's failure to assess R188 immediately after the change in condition and after being found unresponsive created a finding of immediate jeopardy that began on [DATE]. […]
- Immediate jeopardy, isolatedF689Jan 12, 2022
Based on observation, record review and interview, the facility did not ensure that 1 (R4) of 2 residents reviewed for elopement had adequate interventions in place to prevent elopement and accidents. After assessing that R4, who is severely cognitively impaired and frequently voiced that she was leaving, was at risk for elopement, the facility failed to develop and implement interventions to prevent R4 from leaving the facility. Subsequently, R4 eloped from the facility sometime after 1:30 a.m. on 12/3/21 and was found by police walking on a divided four-lane road in the dark, fog, and rain at 3:28 a.m. […]
Read 47 findings in full →The most serious and the most recent: 47 of 242 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 12, 2026Standard and complaint7 findings · 1 harm
- Oct 17, 2024Standard2 findings
- Aug 17, 2023Standard and complaint8 findings · 3 harm
- Jun 30, 2022Complaint5 findings · 1 harm
- Apr 7, 2022Standard and complaint31 findings · 4 harm
- Jan 12, 2022Complaint5 findings · 1 harm
- Oct 27, 2021Complaint2 findings
- Oct 13, 2021Complaint8 findings · 1 harm
Show the 36 earlier surveys
- Sep 9, 2021Complaint1 finding
- May 12, 2021Complaint2 findings
- Apr 7, 2021Complaint3 findings
- Nov 16, 2020Infection control1 finding
- Sep 10, 2020Complaint1 finding
- Jul 1, 2020Complaint1 finding
- Mar 5, 2020Standard and complaint11 findings · 1 harm
- Oct 2, 2019Complaint2 findings · 1 harm
- Jul 10, 2019Complaint5 findings · 1 harm
- Feb 4, 2019Standard and complaint24 findings · 3 harm
- Aug 8, 2018Complaint2 findings
- Jun 14, 2018Complaint2 findings
- Dec 19, 2017Standard and complaint14 findings
- Aug 16, 2017Complaint4 findings
- Mar 20, 2017Complaint3 findings
- Oct 26, 2016Complaint3 findings · 1 harm
- Sep 14, 2016Standard5 findings
- Jul 28, 2016Complaint2 findings
- Mar 1, 2016Complaint8 findings
- Dec 29, 2015Complaint1 finding
- Aug 4, 2015Complaint9 findings
- Jun 17, 2015Standard and complaint14 findings
- Mar 25, 2015Complaint5 findings
- Jan 7, 2015Complaint1 finding
- Oct 7, 2014Complaint1 finding
- Jul 15, 2014Complaint2 findings
- Jun 17, 2014Complaint1 finding
- Apr 23, 2014Standard and complaint11 findings · 3 harm
- Dec 12, 2013—6 findings · 2 harm
- Apr 18, 2013—10 findings · 2 harm
- Feb 21, 2013—1 finding · 1 harm
- Dec 27, 2012—9 findings · 6 harm
- Aug 22, 2012—1 finding
- Feb 27, 2012—2 findings
- Nov 29, 2011—3 findings
- Jan 10, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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